Recent Publications by CFE Educators

BACKGROUND

Thyroid nodules are found in 12-52% of patients with primary hyperparathyroidism (pHPT). With the increasing use of minimally invasive parathyroidectomy (MIP), there is no standard approach for the management of incidental thyroid nodules in pHPT patients.

METHODS

A survey was conducted of the American Association of Endocrine Surgeons. Information was obtained regarding parathyroidectomy practice patterns, including surgical technique, preoperative localization procedures, and algorithms used in the diagnosis/treatment of incidental thyroid nodules.

RESULTS

The survey response rate was 74%. Sixty-seven percent were high-volume parathyroid surgeons (>5/mo); the majority performed MIP. High-volume surgeons were more likely to use Sestamibi/single photon emitted computed tomography for preoperative localization (40% versus 24%; P = 0.011) and to disregard incidentally discovered thyroid nodules 1 cm (41% versus 22%; P = 0.023). They were less likely to evaluate nodules discovered intraoperatively by frozen section (28% versus 41%; P = 0.081), fine-needle aspiration (13% versus 24%; P = 0.078), or thyroidectomy (24% versus 40%; P = 0.03). Surgeons performing open parathyroidectomy were more likely than those who use MIP to biopsy nodules intraoperatively (32% versus 20%; P 0.05) and perform simultaneous thyroidectomy (30% versus 10%; P 0.001).

CONCLUSIONS

Experienced endocrine surgeons disagree about the optimal management of incidental thyroid nodules encountered during parathyroidectomy. Our data suggest that high-volume parathyroid surgeons are less aggressive in their evaluation of thyroid pathology in patients with pHPT. Variation in practice among this experienced group implies even greater variation in the broader surgical community, and in the quality and cost of care for patients with pHPT.

OBJECTIVE

To investigate whether oestrogen, selective oestrogen receptor modulators (SERMs), and growth hormone (GH) can prevent the development of voiding dysfunction in a postpartum postmenopausal rat model of voiding dysfunction.

MATERIALS AND METHODS

Immediately after spontaneous delivery, nine primiparous Sprague-Dawley rats served as uninjured controls (sham group) and 54 underwent intravaginal balloon dilation. On day 7, the 54 subject rats underwent bilateral ovariectomy. A week later, six treatment groups of nine rats were randomized to receive: normal saline (injured control group), 17beta-oestradiol (E(2)), raloxifene, levormeloxifene, GH, or GH + E(2). The treatment groups received daily subcutaneous injections for 3 weeks. The effects of hormone treatment were examined by conscious cystometry at the end of the study. Voiding dysfunction was defined to include overactive bladder and sphincter deficiency.

RESULTS

The sham rats had a mean (sd) voiding frequency of 3 (0.87) times in 10 min and a bladder capacity of 0.43 (0.13) mL with smooth cystometry curves. The number of rats in each treatment group (each group contained nine rats) that had voiding dysfunction was as follows: E(2), three; raloxifene, six; levormeloxifene, four; and controls, four (P > 0.05 among the groups). Only one rat in the GH-treated group and no rats in the GH + E(2)-treated group had voiding dysfunction, which was significantly less in the GH + E(2)-treated group than in the controls (P = 0.041).

CONCLUSION

This functional data suggest that the development of voiding dysfunction can be prevented by short-term administration of GH and GH + E(2) in our rat model. SERMs and E(2) alone seem to have no therapeutic effect.

Medullary thyroid cancer (MTC) is a neuroendocrine tumor derived from the C cells of the thyroid. C cells are responsible for the production of calcitonin, a sensitive and specific marker for MTC. Early detection of MTC is essential; overall survival from MTC is related to patient age, stage of disease and extent of surgical resection. Elevated preoperative serum calcitonin levels have been shown to predict the likelihood of biochemical remission postoperatively. The use of routine serum calcitonin measurements as a screening measure for MTC in patients with thyroid nodules has been advocated in Europe. To date, routine calcitonin measurement has not been widely practiced in the USA; a recent cost-effectiveness analysis suggests routine serum calcitonin measurements in patients with thyroid nodules may be comparable to other widely accepted screening programs.

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in women in the United States. The purpose of this study was to characterize the prevalence and awareness of traditional CVD risk factors, obesity, and coronary heart disease (CHD) risk classification using the Framingham Risk Score (FRS) among women attending the 2006 Sister to Sister National Woman's Heart Day event.

RESULTS

A total of 8936 participants (mean age 49 +/- 14 years) were evaluated. There was a modest prevalence of traditional risk factors on screening, including non-high-density lipoprotein-cholesterol (HDL-C) >160 mg/dL (27%), HDL-C 40 mg/dL (16%), random glucose level >140 mg/dL (6%), uncontrolled blood pressure > or =140/90 mm Hg (12%), current smoking (6%), and a positive family history of CHD (21%). There was a high prevalence of overweight (39%) or obese individuals (35%) (body mass index [BMI] 25-30 and > or =30 kg/m(2), respectively), as well as those with high waist circumference (> or =35 inches) (55%). Women were classified by FRS as low (85%), intermediate (6%), and high risk (9%). When cardiometabolic risk analyses included waist circumference in addition to the FRS, 59% of low-risk and 50% of intermediate-risk women had 1 or 2 risk factors, and 19% and 41% had > or =3 risk factors, respectively. Women were often unaware of risk factors on screening; among women without a previous diagnosis of dyslipidemia or hypertension, 48% and 7%, respectively, were given new diagnoses.

CONCLUSIONS

Women participating in the 2006 Sister to Sister National Woman's Heart Day event have a high prevalence of cardiometabolic risk factors, especially dyslipidemia, obesity, and high central adiposity, that place them at higher risk for the development of CVD and other comorbidities. The newly identified multiple risk factors in this population support the value of community health screening in women.

INTRODUCTION

Infertility has been associated with anxiety, stress, and sexual problems in both men and women.

AIM

To assess quality of life, sexual health, and depression in the female partner of infertile couples.

METHODS

Couples presenting for the evaluation of infertility at two tertiary care medical centers were invited to participate in a survey study.

MAIN OUTCOME MEASURES

Female partners completed the Female Sexual Function Index (FSFI) and a modified Self-Esteem and Relationship (SEAR) Questionnaire. Male partners completed the SEAR and the International Index of Erectile Function (IIEF). Both partners completed the Center for Epidemiological Studies Depression Scale (CES-D) for depression and the Short Form-36 (SF-36) for general quality of life. Demographic, fertility, and comorbidity information was recorded.

RESULTS

One hundred and twenty-one couples constitute the study population. Mean female and male age was 32 +/- 5 and 35 +/- 7 years, respectively. Most (92%) couples were married. Mean duration of relationship and marriage were 6.4 +/- 3.9 and 3.8 +/- 3.2 years, respectively. Mean duration of attempted conception was 24 +/- 24 months. On CES-D, 19% of women had moderate and 13% had severe depression. Women reported significantly worse SF-36 Mental Health subscale scores (mean = 47.8, P 0.05) compared with normative values. The mean total FSFI score was 28 +/- 7 (maximum score of 36), with 26% of the women scoring below 26.55, an established cut-off for high risk of female sexual dysfunction. FSFI scores had a modest positive correlation with male IIEF scores (r = 0.37, P 0.01), and there was a trend toward a negative correlation with female CES-D scores (r = -0.16, P 0.06). These relationships were maintained on multivariate analysis.

CONCLUSIONS

Depression and sexual dysfunction are prevalent in female partners of infertile couples. Female sexual function is positively correlated with male partner sexual function in this population.

RATIONALE

Microvascular injury, inflammation, and coagulation play critical roles in the pathogenesis of acute lung injury (ALI). Plasma protein C levels are decreased in patients with acute lung injury and are associated with higher mortality and fewer ventilator-free days.

OBJECTIVES

To test the efficacy of activated protein C (APC) as a therapy for patients with ALI.

METHODS

Eligible subjects were critically ill patients who met the American/European consensus criteria for ALI. Patients with severe sepsis and an APACHE II score of 25 or more were excluded. Participants were randomized to receive APC (24 microg/kg/h for 96 h) or placebo in a double-blind fashion within 72 hours of the onset of ALI. The primary endpoint was ventilator-free days.

MEASUREMENTS AND MAIN RESULTS

APC increased plasma protein C levels (P = 0.002) and decreased pulmonary dead space fraction (P = 0.02). However, there was no statistically significant difference between patients receiving placebo (n = 38) or APC (n = 37) in the number of ventilator-free days (median [25-75% interquartile range]: 19 [0-24] vs. 19 [14-22], respectively; P = 0.78) or in 60-day mortality (5/38 vs. 5/37 patients, respectively; P = 1.0). There were no differences in the number of bleeding events between the two groups.

CONCLUSIONS

APC did not improve outcomes from ALI. The results of this trial do not support a large clinical trial of APC for ALI in the absence of severe sepsis and high disease severity.

OBJECTIVE

Colonoscopy, the "gold standard" screening test for colorectal cancer (CRC), has known diagnostic limitations. Advances in endoscope technology have focused on improving mucosal visualisation. In addition to increased angle of view and resolution features, recent colonoscopes have non-white-light optics, such as narrow band imaging (NBI), to enhance image contrast. We aimed to study the neoplasia diagnostic characteristics of NBI, by comparing the neoplasm miss rate when the colonoscopy was performed under NBI versus white light (WL).

DESIGN

Randomised controlled trial.

SETTING

US Veterans hospital.

PATIENTS

Elective colonoscopy adults.

INTERVENTION

We randomly assigned patients to undergo a colonoscopic examination using NBI or WL. All patients underwent a second examination using WL, as the reference standard.

MAIN OUTCOME MEASURES

The primary end point was the difference in the neoplasm miss rate, and secondary outcome was the neoplasm detection rate.

RESULTS

In 276 tandem colonoscopy patients, there was no significant difference of miss or detection rates between NBI or WL colonoscopy techniques. Of the 135 patients in the NBI group, 17 patients (12.6%; 95% confidence interval (CI) 7.5 to 19.4%) had a missed neoplasm, as compared with 17 of the 141 patients (12.1%; 95% CI 7.2 to 18.6%) in the WL group, with a miss rate risk difference of 0.5% (95% CI -7.2 to 8.3). 130 patients (47%) had at least one neoplasm. Missed lesions with NBI showed similar characteristics to those missed with WL. All missed neoplasms were tubular adenomas, the majority (78%) was or = 5 mm and none were larger than 1 cm (one-sided 95% CI up to 1%). Nonpolypoid lesions represented 35% (13/37) of missed neoplasms.

INTERPRETATION

NBI did not improve the colorectal neoplasm miss rate compared to WL; the miss rate for advanced adenomas was less than 1% and for all adenomas was 12%. The neoplasm detection rates were similar high using NBI or WL; almost a half the study patients had at least one adenoma. Clinicaltrials.gov identifier: NCT00628147.

CONTEXT

Clinical and economic outcomes after thyroidectomy/parathyroidectomy in adults have demonstrated disparities based on patient age and race/ethnicity; there is a paucity of literature on pediatric endocrine outcomes.

OBJECTIVE

The objective was to examine the clinical and demographic predictors of outcomes after pediatric thyroidectomy/parathyroidectomy.

DESIGN

This study is a cross-sectional analysis of Healthcare Cost and Utilization Project-National Inpatient Sample hospital discharge information from 1999-2005. All patients who underwent thyroidectomy/parathyroidectomy were included. Bivariate and multivariate analyses were performed to identify independent predictors of patient outcomes.

SUBJECTS

Subjects included 1199 patients 17 yr old or younger undergoing thyroidectomy/parathyroidectomy.

MAIN OUTCOME MEASURES

Outcome measures included in-hospital patient complications, length of stay (LOS), and inpatient hospital costs.

RESULTS

The majority of patients were female (76%), aged 13-17 yr (71%), and White (69%). Whites were more often in the highest income group (80% vs. 8% for Hispanic and 6% for Black; P 0.01) and had private/HMO insurance (76% vs. 10% for Hispanic and 5% for Black; P 0.001) rather than Medicaid (13% vs. 32% for Hispanic and 41% for Black; P 0.001). Ninety-one percent of procedures were thyroidectomies and 9% parathyroidectomies. Children aged 0-6 yr had higher complication rates (22% vs. 15% for 7-12 yr and 11% for 13-17 yr; P 0.01), LOS (3.3 d vs. 2.3 for 7-12 yr and 1.8 for 13-17 yr; P 0.01), and higher costs. Compared with children from higher-income families, those from lower-income families had higher complication rates (11.5 vs. 7.7%; P 0.05), longer LOS (2.7 vs. 1.7 d; P 0.01), and higher costs. Children had higher endocrine-specific complication rates than adults after parathyroidectomy (15.2 vs. 6.2%; P 0.01) and thyroidectomy (9.1 vs. 6.3%; P 0.01).

CONCLUSIONS

Children undergoing thyroidectomy/parathyroidectomy have higher complication rates than adult patients. Outcomes were optimized when surgeries were performed by high-volume surgeons. There appears to be disparity in access to high-volume surgeons for children from low-income families, Blacks, and Hispanics.